Compression

Ready-to-Wear Stockings *Medicare will only cover compression above 30mmHg*

(check one) Toe

(check one)

REFERRAL INFORMATION

Open Toe Closed Toe

Quantity (Pair):_______________________________

Assignment of Benefits: I request that payment of my insurance benefits be made to CHC Solutions, Inc., or any of its subsidiaries, for any supplies or services they provide me. I am responsible for any balance due that is not covered by my insurance. I understand any product received in my home cannot be returned if opened. By signing below, I authorize the distribution of my information to CHC Solutions, Inc., or any of its subsidiaries, which may be needed to determine benefits payable for these services or supplies. I authorize CHC Solutions, Inc., or any of its subsidiaries, to forward my medical records to the medical professionals in my care and/or make copies of said records.

Patient Signature:________________________________ Date:______/______/___________

Physician Name: ______________________________ NPI#: _____________ Phone: (_____)_____-_______ Ext. _______

Physician Signature: _________________________________ Date: ______ /______ /_________I certify that the above products are medically necessary and that the information provided is accurate to the best of my knowledge. By signing below, I acknowledge that I have obtained the patient’s authorization to release the above information and other medical information that may be disclosed. I certify that my decision to prescribe this recommended product was solely based on my determination of medical necessity set forth herein. This document may serve as a confirmation of a verbal order and is also recorded in the patient’s record.

Practice Name:______________________________________________ Fax: _____________________________________

Office Address: ____________________________________________ Email: _____________________________________

Phone: ____________________________________________ Preferred Method of Contact? M Phone M Fax M Email

Patient Name: ______________________________________________________________________________________

DOB: ______ /______ /_________ Start Date: ______ /______ /_________ Gender: M Male M Female

Language Pref.: M English M Spanish M Other: ___________________________

Emergency Contact Name/Phone Number: ______________________________________________________________

Length of Need: __________________________ Months

**Please attach face sheet w/ patient demographics & insurance info**

PATIENT INFORMATION

PRODUCT SELECTON

30-40mmHg(medical)

40-50mmHg(medical)

What type of compression are you ordering for the patient (Knee High Only):

Left Leg Right Leg

Ankle Circumference

Calf Circumference

Length from knee to floor

Order Date ____/____/____ Start Date ____/____/____ Number of Refills_____

Ref #: ____________________

** Medicare and Medicare Replacement Plans require patients have an open, measurable venous stasis ulcer. If patient does not have a venous stasis ulcer, we will discuss private pay with the patient**

JOBST Relief Stockings

Circaid JuxtaLite Circaid JuxtaLite HD Carolon Multi-layer Stockings Activa Stockings

Mediven Dual Layer Stocking System

Color(check one)

Black Beige

JOBST FarrowWrap

WOUND ASSESSMENTDrainage

M None M Min M Mod M Hvy

M None M Min M Mod M Hvy

Stage/Thickness Length x Width x DepthHas the wound ever been debrided?

Wound LocationICD-10 Code

1.

2.

M 2 M 3 M 4 M Partial M Full M YES M NO

M YES M NO M 2 M 3 M 4 M Partial M Full

JOBST FarrowWrap 4000 CompreFLEX Lite JOBST UlcerCARE

COMPRESSION STOCKINGS PRESCRIPTION FORM

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PHONE: 1.844.493.4013 FAX: 1.844.317.9378 EMAIL: orders@healthsourcemedicalsupply.com